Transforming Gender Norms

Gender norms stand in the way of reducing HIV; indeed, a recent study states that, "The global HIV pandemic in its current form cannot be effectively arrested without fundamental transformation of gender norms" (Dunkle and Jewkes, 2007: 173). As former U.S. Secretary of State Hillary Clinton stated: "Achieving our objectives for global development will demand accelerated efforts to achieve gender equality and women's empowerment" (USAID, 2012b: i). The evidence is mounting that gender norms harm both women's and men's health (Barker et al., 2007b). Yet the social constraints women face that make them particularly vulnerable to HIV include gender norms that privilege men over women in most societies. Experts in development and gender increasingly agree that interventions to address gender norms and reduce HIV need to work with "men and women, boys and girls, in an intentionally and mutually reinforcing way that challenges gender norms, catalyzes the achievement of gender equality and improves health" (Greene and Levack, 2010: vi).

"...Reflections on men and HIV/AIDS are usually limited to their culpability as drivers of the epidemic. Addressing these issues effectively means moving beyond laying blame, and starting to develop interventions to encourage uptake of prevention, testing and treatment for men -- for everyone's sake" (Mills et al., 2009: 276).Programming that works to change the attitudes and practices of men and boys -- the younger the better -- is essential to reducing HIV risk in women (Abdool Karim et al., 2010a: S124). Yet as some have recently argued, HIV "... programs and policies [have] largely failed to include the prevention needs of men who have sex with women..." (Higgins et al., 2010: 435). Since it is in both men's and women's interest to avoid HIV infection, "men can and should play an active role in HIV prevention" (Higgins et al., 2010: 441). While many international agencies in the global HIV response have endorsed the importance of engaging men as the traditional sexual decision makers, most interventions involve men as instruments to improve women's or children's health.

Depending on how men are involved, interventions can potentially increase the disempowerment of women (Montgomery et al., 2011). Some interventions may similarly sideline attention to men, who also need to have their health needs met, beyond their support for women's health. Programs must work in overlapping and complimentary ways with men and boys as clients; involving men to improve women's health; and to promote a positive shift away from dominating gender attitudes and behaviors (Peacock et al., 2009; www.men-care.org). Research shows that there are HIV-positive men want to protect their wives from acquiring HIV. As one man living with HIV in Uganda put it: "That thing that forced me to disclose to her where we stand, because I was thinking for her she might be negative. If she was negative, she would remain behind when I die to look after the children. But if she was positive, then we could see how we could protect ourselves and our children"(Ssali et al., 2010: 678).

"I don't want to look for another woman who will bring diseases from outside and then it gets transmitted to my wife. If our child is born and has this disease, I would feel very much about this, so I cannot do it." -Mozambican man (Bandali, 2011a: 583)A man living with HIV in Kenya stated, "I have changed. I am not like before, I have actually been using protection so that I do not infect my HIV-negative wife. I also avoid extra-marital affairs"(Sarna et al., 2009: 786). Separate focus group discussions with men and women in Mozambique found that both sexes viewed men as "superior, dominant and decision-makers, while women are considered subservient, passive and obedient" (Bandali, 2011a: 578). Even some men who portrayed these dominant characteristics wanted to protect their families.Many women and men are taking action to prevent HIV transmission but gender norms can sometimes impede communication between partners. HIV-positive men in the Kenya study above also described their struggles to negotiate condom use: "I explained to her we use condoms, I have the disease... and then she tells me, she does not believe it, lets do away with it [the condom]" (Sarna et al., 2009: 788). In contrast, a South African woman living with HIV described her efforts to persuade her cohabitating boyfriend to use condoms: "He doesn't take it seriously, he says I'm the one who has a problem, he doesn't" (Christofides and Jewkes, 2010: 282). Women in the Christofides and Jewkes study in South Africa wanted their partners to engage in the full range of behaviors to prevent HIV but found it difficult to influence them. Surveys from Chad, Ghana, Malawi, Nigeria, Tanzania, Uganda, Zambia and Zimbabwe found that higher levels of extramarital sexual risk-taking by men was more prevalent in communities characterized by less gender equity (Stephenson, 2010). Women face an imbalance of power in negotiating the terms of condom use. [See also Male and Female Condom Use]

Traditional Gender Norms Lead to Behaviors That Put Women -- And Men -- at Risk for HIV

For both women and men, gender norms are codified through public policy in a range of sectors/areas including health and employment (Barker et al., 2010a). Gender norms, including those that influence sexual and power relations, influence all program areas related to HIVAIDS, from prevention to treatment, care and support. Traditional gender norms lead to behaviors that put everyone at risk for acquiring HIV. Women are less likely to have access to resources and are more likely to depend on men for financial survival for themselves and their children. For many women, having more than one partner is a central survival strategy for themselves and their children. Such dependence makes it difficult to negotiate safer sex with partners. A study in Mozambique, for example, found that men and women agreed that for women, the only way of getting money was to have sex. Poor women with children would have to have multiple partners. Regardless of the circumstances, women tend to be blamed for spreading HIV, not the men (Bandali, 2011a). A study in Haiti showed that to balance the multiple demands of family and economic survival and to obtain food and housing, single mothers enter into a series of sexual relationships (Fitzgerald et al., 2000). A study in Tanzania found that 70 percent of sexually active girls reported granting sexual favors to meet their basic daily needs (Maganja et al., 2007). Yet whatever puts women at lower risk of acquiring HIV will also ultimately affect the risk of HIV acquisition for men.

Women's dependence makes it difficult for them to negotiate the terms of sex with their partners. These norms may limit women's mobility. Relationship power inequity and intimate partner violence increased the risk of incident HIV infection among 128 South African women who acquired HIV in a 2002-2006 study of 2076 person-years of experience (Jewkes et al., 2010b). It may be that concurrency, rather than relationship power inequity is key to reducing HIV (Epstein, 2010). Some contend that having multiple partners can engender violence (Castor et al., 2010), but others have presented data that do not show a relationship between concurrency and violence (Jewkes and Dunkle, 2010).

Nonetheless, in sexual relationships, women often lack the power to protect themselves, and there are close connections between gender inequality and violence against women (WHO, 2010f: 9). [See Addressing Violence Against Women]

Traditional Gender Norms Also Harm Men

"People say that cooking and child care are duties of the wife... But I don't see anything wrong in cooking and looking after the children... Doing such chores can help me, because, if my wife falls ill, I will be able to cook for her and the children..." -Male patient on antiretrovirals in Zimbabwe (Skovdal et al., 2011)Men are also affected by gender norms that define masculinity as including early, risky sex with multiple partners and limited communication (Barker et al., 2007b; Pulerwitz et al., 2010b). The 1,268 participants in a study in Botswana who held three or more gender discriminatory beliefs had nearly three times the odds of having had unprotected sex in the past year with a non-primary partner as those who held fewer such beliefs (PHR, 2007a). Homophobia makes men who have sex with men more likely to marry a woman to diminish stigma and legal or other consequences, where homosexuality is illegal (White and Carr, 2005). [See also Partner Reduction] In many settings, men also tend to seek out health services less than women. And when men do seek health care, they may not be offered information on how to lead a healthy sex life, and the sexual health concerns of men living with HIV and AIDS are frequently neglected (Esplen, 2007). A study in China with ten AIDS health professionals and 21 adults living with HIV found that "power differences between men and women, men's dominant role in sexual life and their ignorance about HIV/AIDS and its prevention contribute to the increasing HIV risk faced by women" (Zhou, 2008: 1119).

When masculinity is equated with sexual risk-taking and control over women, men are less likely to use condoms, more likely to have more partners, more casual partners, and to engage in more transactional sex (Greig et al., 2008). A qualitative study of six groups of 5 to 10 participants meeting once per week for three weeks in rural South Africa with sexually experienced young people ages 14 to 19 found that young men universally felt that female virginity was a desirable characteristic (Harrison, 2008). However, once in a relationship, boyfriends often insisted on sexual intercourse to establish that their girlfriend was a virgin. Young women acquiesced, as they believed that their virginity should be saved for the right partner -- and that this partner was the one. Young women then lost their valued status as virgins in the process of proving virginity, with some young women claiming coercion: "...he forces you to have sex to prove to him that you are still a virgin" (Harrison, 2008: 185). Transforming attitudes towards gender equity have been successful in young adolescents and in men as well as women (IRH, 2011; Promundo et al., 2012).

Changing Gender Norms Requires Synchronized Programming for Both Men and Women

The role of gender norms in fueling the AIDS epidemic is clear but insufficiently addressed in programs (UNIFEM, 2008). For example, AIDS programs face a gender-related paradox that in most countries, women are more vulnerable to HIV transmission--in Africa, 61 percent of new HIV cases are in women--yet statistics on treatment show that more women than men access ARV services. Both statistics are related to gender norms that discourage women from obtaining knowledge about sex and protection and discourage men from seeking health care. Working to help people question gender norms, "the societal messages that dictate appropriate or expected behavior for males and females--is increasingly recognized as an important strategy to prevent the spread of HIV infection" (Pulerwitz et al., 2006: 1).

There seems to be some convergence on the idea that "gender relational programming" that works with both women and men -- in the same or different ways -- may be most successful in shifting gender norms in a more equitable direction, with positive impacts on health (Greene and Levack, 2010). Meaningful or constructive male involvement has been defined as involving men in in three overlapping roles: as clients of reproductive health services; as supportive partners to women; and as agents of change in the family and community (Greene, 2006). Program and policy interventions can make positive changes in men's gender-related attitudes and behaviors (Barker et al., 2010c) and numerous programs have shown results in addressing gender norms with men to reduce HIV risks (Colvin, 2009; Pulerwitz et al., 2006), but these programs reach a tiny fraction of the population in need (Barker et al., 2010b). Additional programming and evaluations are needed for boys under the age of 15 and for longer than two-year time spans (Barker et al., 2010b).Some of the most effective interventions involve working with young boys to promote gender equitable attitudes and behaviors. At the same time, attention to public policies that reinforce or transform gender norms for both women and men is critical (Barker et al., 2010a). It's clear that additional programming and evaluations are needed in three key areas: 1) for boys under the age of 15; 2) for longer than two-year time span; and 3) to work at the policy level (Barker et al., 2010b).

Some programming can reinforce traditional gender norms. PAHO analyzed gender roles in 200 HIV-related public service announcement TV spots from Latin America and found that TV spots tended to reinforce the traditional gender roles that contribute to the HIV epidemic, with women bearing sole responsibility for HIV prevention and men as more interested in sex than women (Parodi and Lyra, 2008). It is critical to change prevailing gender norms that dictate multiple sexual partners for men and sexual ignorance and submissiveness for women and girls.

While this section focuses on transforming gender norms, several other interventions that influence gender norms are featured in the rest of the chapter as they relate to violence against women, women's legal rights, employment, education, etc. Changing gender norms requires political will and leadership at every level, from national policymakers to public sector implementers to community leaders. A multi-pronged approach is needed to work with individual men to help them question harmful gender norms and support safer sexual behavior, as well as with the media, community, religious leaders and others who can influence gender norms.